Health History and Consent

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First Name *

Last Name *

Home Phone #: *

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Cell Phone #:

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Work Phone #:

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Email *

Home Address

Street Address *

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City *

State *

Zip *

Is your Mailing Address the same as your Home Address? *YesNo

Mailing Address

Street Address

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City

State

Zip

Occupation *

Date of Birth *

Age *

Sex *MaleFemale

Emergency Contact *

Relationship to Client *

Emergency Contact Phone #: *

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Primary Physician *

Health Insurance Carrier *

How did you hear about me? *

Health History

Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to treatment.

Have you ever experienced a professional massage or spa treatment? *YesNo

How recently?

What are your massage or bodywork goals? *

What kind of pressure do you prefer? *LightMediumFirm

Have you been under the care of a physician, dermatologist or other medical professional within the past year? *YesNo

Please explain:

Conditions

Please check any conditions you currently have or have had in the past. If a text box appears for any condition you check, please explain it in the box.

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

By clicking here I indicate my understanding and agreement to the Consent Statement above. *

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